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Dorsal preservation involves eliminating the dorsal hump by performing reduction while preserving the patient's natural dorsal anatomy. This can involve surface manipulation or foundational techniques or a combination of both. When surgeons begin performing dorsal preservation, there are important factors to consider to avoid complications. In an effort to inform surgeons on how to avoid unfavorable outcomes, I will discuss my first 20 cases where I performed dorsal preservation. I review less than ideal outcomes and how these issues can be prevented.

Preservation rhinoplasty is making a resurgence as a reliable method of performing primary rhinoplasty. Dorsal preservation is an important part of the approach to preserve favorable nasal contours when performing rhinoplasty. Keys to success require proper patient selection and careful execution. There are potential sequelae, such saddle nose deformity, recurrence of the dorsal convexity, cerebrospinal fluid leak, and radix step-off. This article discusses methods and adjustments in technique to help minimize these potential problems when performing dorsal preservation.

Nasal valve collapse has multiple causes, including congenital, traumatic, and, unfortunately, iatrogenic. Recognition of the causes of nasal valve collapse and the methodology for treatment is paramount not only for the otolaryngologist but also for any physician managing the nasal airway. This article focuses on the cause and surgical management of internal and external nasal valve collapse.

In facial plastic surgery, attaining hemostasis may require adjuncts to traditional surgical techniques. Fibrin tissue adhesives have broad applications in surgery and are particularly useful when addressing the soft tissue encountered in facial plastic surgery. Beyond hemostasis, tissue adhesion and enhanced wound healing are reported benefits associated with a decrease in operating time, necessity for drains and pressure dressings, and incidence of wound healing complications. These products are clinically accessible to most physicians who perform facial plastic surgery, including skin grafts, flaps, rhytidectomy, and endoscopic forehead lift.

After completion of this article, the reader should be able to describe the indications for lateral crural repositioning, understand the key steps to performing the procedure, and be able to manage the complications associated with this treatment strategy.

UNLABELLED What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?' ANALYSIS Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

Maintaining structural integrity during rhinoplasty often necessitates adding support to the nose. Autologous grafting material is the safest and most reliable source of this structural support. A variety of sources in the body can serve as donor sites for such grafts. The most common sites are septal cartilage, auricular conchal cartilage and rib cartilage. Less common sites include tragal cartilage, calvarial bone and iliac bone. This article reviews the surgical techniques for accessing, harvesting, and modifying these grafts for use in rhinoplasty.

This article describes the equipment and software used to create facial 3D imaging and discusses the validation and reliability of the objective assessments done using this equipment. By overlaying preoperative and postoperative 3D images, it is possible to assess the surgical changes in 3D. Methods are described to assess the 3D changes from the rhinoplasty techniques of nasal dorsal augmentation, increasing tip projection, narrowing the nose, and nasal lengthening.

The crooked nose deformity and the saddle nose deformity represent two of the most challenging complications of nasal trauma. Optimal management requires careful preoperative analysis and thoughtful surgical planning. The surgeon must make the mental and philosophical commitment to address the difficult cosmetic components and the functional problems related to these deformities. Because these conditions result from disruptions of the nasal septum, their surgical correction mandates use of techniques that modify the septum, and they might require reconstruction of the sacrosanct dorsal-caudal strut. By understanding the three-dimensional anatomy of this L-shaped strut, how its relationship to the other structural components of the nose determines external nasal contour, and the techniques available to stabilize this structure into an optimal position, the surgeon can correct these difficult cosmetic problems effectively while maintaining the overall structural and functional integrity of the nose.

The lateral periorbital area represents one of the earliest and most bothersome facial stigmata of aging. Although traditional techniques have had limited success in treating the static cutaneous component to rhytid formation in this region, they have been largely unsuccessful in addressing the dynamic hyperkinetic lines that are created by the activity of the lateral orbicularis oculi muscle. Botox A injection represents a safe and reproducible technique to selectively denervate muscle activity in this troublesome area. This minimally invasive technique has led to significant improvement of periorbital lines, either when used as a single agent or in combination with other methods (Fig. 3). As more experience is gained with this toxin, as well as other Botox serotypes, continued progress is likely to occur in this area, as well as in other facial regions.

David W. Kim, MD*, Dean M. Toriumi, MD Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of California at San Francisco, 400 Parnassus Avenue A-730, San Francisco, CA 94143-0342, USA Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of Illinois at Chicago, 1855 West Taylor Street, Chicago, IL 60612, USA

Surgical tissue adhesives continue to evolve as an important technology for the facial plastic and reconstructive surgeon. Twelve years ago there was little routine use of these substances; however, in the past 5 years there have been significant advances. It is becoming increasingly important for the facial plastic and reconstructive surgeon to be familiar with the indications and shortcomings of these compounds. This article will summarize the evolution of surgical tissue adhesives to their present-day applications, including technical points for their successful use. An ideal surgical tissue adhesive must meet the following criteria: strong binding strength, ease of application, tissue biocompatibility, biodegradable byproducts, minimal tissue reactivity, and reasonable cost. Currently available surgical tissue adhesives can be categorized as either fibrin tissue adhesives or cyanoacrylates. Although fibrin tissue adhesives and cyanoacrylates are often discussed under the general topic of surgical tissue adhesives, these two substances have different indications and mechanisms of action. Fibrin tissue adhesives use naturally occurring substrates that are part of normal endogenous clotting mechanisms. In contrast, the adhesion achieved by cyanoacrylates is a result of synthetic compounds not naturally occurring in the human body. These two types of adhesives also have different clinical indications. Fibrin tissue adhesives are typically applied below the dermis as a biologic hemostat or as a sealant for use with skin grafts and flaps. Cyanoacrylates have been shown to be histotoxic when applied below the dermis and have been used most successfully at the level of the epidermis for superficial skin closure [1].

Congenital abnormalities of the auricle span a spectrum of abnormalities from total anotia to slight asymmetries of an otherwise normal appearing ear. This article is dedicated to the management of the prominent, or protruding ear. A number of well-known surgical techniques have been described for the correction of the protruding ear. The ideal set of techniques must accomplish several goals. The desired post-operative results must include (1) a normal appearing auricular contour from both the frontal and lateral views, (2) an absence of unnatural sharp edges in the cartilage framework, and (3) symmetry of both ears. The techniques involved must be relatively easy to learn and must also yield reproducible results.

Cyanoacrylate and fibrin tissue adhesives can aid the facial plastic surgeon performing surgery in the outpatient setting. Octyl-2-cyanoacrylate is ideal for superficial skin closure and eliminates the need for suture removal. Subcutaneous sutures are needed in most cases to provide the best cosmetic outcomes. Fibrin tissue adhesives can be used to aid in attaining hemostasis or to seal or fixate tissues. Cyanoacrylate and fibrin-based adhesives can simplify office-based facial plastic surgery.

When performing nasal tip surgery, a stable nasal base is critical in providing a good long-term outcome. Weakness in the nasal base can result in postoperative loss of nasal tip projection. Patients with a deficiency in the nasal base include those with inadequate tip projection, acute nasolabial angle, and dependency of the nasal tip. Maneuvers used to stabilize the nasal base include a sutured-in-place columellar strut, caudal extension graft, setting back and fixating the medial crura to an overly long caudal septum, or use of an extended columellar strut fixated to the periosteum about the nasal spine. Once the nasal base is stabilized, the lobule can be modified using domebinding sutures or a sutured-in-place tip graft. Use of these maneuvers can provide maximal tip projection with good tip contour. This article will discuss the principles behind the use of these techniques and discuss the nuances related to execution of the maneuvers.

Advances in surgical instrumentation are generally intended to allow the performance of a surgical maneuver more efficiently and accurately. Powered instrumentation may allow improved precision and ease in certain aspects of rhinoplasty and septoplasty. Through improved precision, tissue trauma can be minimized.

The quest for nasal symmetry and balance with the face often mandates the need for implantable materials to sculpt and rebuild the nasal skeleton and the overlying tissues. A suitable implant must be biocompatible, strong, and elastic. Implant materials that may be used in the nose can be divided into four groups: autografts, homografts, xenografts, and alloplasts. Each type of implant is reviewed and discussed in the context of rhinoplasty and nasal reconstruction.

The region of the face where the nose, lip, and cheek join is both visually and three-dimensionally complex. Numerous skin flaps and grafts have been used to reconstruct this region. Such reconstruction often results in poorly defined or amorphous facial features. This article uses one prototype case to show how flaps and grafts can be turned into tissue forms that when truly normal look like the features of the face. The emphasis is on dimension, proportion, and form. A stable platform for the nose is first constructed. The nose is sited. A thin, flexible lining is created. A lamina of cartilage and bone grafts is established throughout the defect. Three-dimensional patterns and nasal models are used. Refinement of the contour is performed before the pedicle is divided. Incisions are placed in facial lines of deepest shadow. Important details of the facial bas-relief are carved out of flap tissues.

Cartilage suturing techniques used to alter nasal tip shape are reliable and effective in patients who may be difficult to manage because of variant anatomy. Patients with thin nasal tip skin may present problems with visible deformity (edges, bossae, etc) after aggressive cartilage excision, dome division, or tip grafting. Cartilage suturing techniques (transdomal suture, domal suture, etc) are particularly effective in patients with strong cartilages and tip bulbosity. These techniques can also provide increased tip projection and rotation. Cartilage delivery or the external rhinoplasty approach provides the exposure necessary to place these sutures. This article describes several different techniques of suturing tip cartilages that will provide precise narrowing of the nasal tip as well as increase tip projection and rotation. Modifications of the suturing techniques are based primarily on the anatomy of the lower lateral cartilages and desired contour changes.

The incidence of aesthetic and functional complications of rhinoplasty can be decreased by preserving supportstructures of the nose. This is particularly important in patients at high risk for collapse of the middle nasal vault (cartilaginous nasal vault). Aggressive surgical manipulation of the upper lateral cartilages can result in excessive narrowing of the middle vault and collapse of the internal nasal valve. Spreader grafts can be used to provide appropriate width to the middle vault and preserve nasal valve function. This paper will discuss indications and technique for application of spreader grafts using the open rhinoplasty approach. Spreader grafts can be used in high risk patients with short nasal bones, long weak upper lateral cartilages, thin skin, and narrow projecting nasal vault. These patients are at higher risk for excessive narrowing of the middle vault (inferomedial collapse of upper lateral cartilages) because of loss of medial support after hump removal. Spreader grafts will support the lateral nasal wall, preserve nasal width, and prevent deformity. Spreader grafts can also be used to add width to the cartilaginous vault in disproportioned noses that have an excessively narrow middle vault and broad nasal tip. This maneuver will allow the surgeon to perform conservative narrowing of the nasal tip and prevent deformity or compromise of nasal function. Spreader grafts can be used in combination with lateral crural grafts or alar batten grafts to correct secondary deformities of the internal and/or external nasal valve. Conservative reduction and thoughtful augmentation in rhinoplasty will preserve nasal support and function with improved long-term results.

The concept of non-surgical implantation of injectable filler materials for soft-tissue augmentation has always been an attractive option for the head and neck surgeon. The ideal injectable soft tissue filler material would be easy to use, biocompatible, nontoxic, and long-lasting. Presently available filler materials present significant drawbacks to their use. The most favorable filler materials appear to be autologous fat and microparticulate alloplasts. This article reviews presently used injectable filler materials and those that may be used in the future.

The primary surgical tissue adhesives used in otolaryngology-head and neck surgery include the cyanoacrylate derivatives and the fibrin tissue adhesives. The cyanoacrylate derivatives are effective for superficial skin closure. Use of this material below the level of the skin can result in acute and chronic inflammation and tissue necrosis. Fibrin tissue adhesives can be used for wound closure, tissue sealing, and hemostasis. Drawbacks noted with the fibrin tissue adhesives include method of preparation, relatively low binding strength, and variable resorption time. This article discusses the properties, methods of preparation, and clinical indications of the cyanoacrylate derivatives and fibrin tissue adhesives.

Aesthetic surgery of the non-Caucasian nose frequently requires aggressive surgical manuevers to attain the desired changes in nasal contour. Unfortunately, thick, sebaceous skin of the non-Caucasian nose is at great risk for increased scar contracture, which could deform an already weak nasal structure. To prevent deformity, we use the open structure rhinoplasty technique to add support to the nasal structure in the form of columellar struts and sutured-in-place tip grafts. In this article, specific modifications of the open structure rhinoplasty technique are described for management of the non-Caucasian nose.

Recognition of the aesthetic range of acceptability of nasal projection is crucial to sophisticated rhinoplastic surgery. Within this article, various methods are discussed that use measurements of ratios and angles between facial landmarks to assist the surgeon in assessment of nasal projection. Chin projection, skin thickness, and patient age are further considerations when deciding how to best approach an aesthetic ideal for a particular patient's face. This article then discusses preoperative assessment and diagnosis and emphasizes steps taken to correct problems of projection that completely depend on the anatomic etiology of the deformity.

Most techniques that control tip projection involve relatively aggressive maneuvers that can compromise the integrity of the nasal structure by dividing major support mechanisms, or dramatically alter the shape of the nasal tip by cutting the lower lateral cartilage and re-orienting the domes. Decreased tip support can result in an iatrogenic loss in tip projection that may require compensatory over-reduction of the nasal dorsum. This series of events may result in a blunted nose with a poorly defined dorsum. Open structure rhinoplasty techniques emphasize preservation or reconstitution of major support mechanisms to attain a natural-looking nose that will not deteriorate with time. This technique uses the open (external) approach to the nose, sutured-in-place columellar strut, advanced lateral crural manipulation, and a sutured-in-place tip graft to provide tip projection, support, and a bidomal tip configuration. This article discusses the theory, major technical points, and use of this technique for precise control of tip projection.

The transconjunctival approach to removal of herniated orbital fat is the method of choice in patients with no evidence of dermatochalasis or hypertrophic orbicularis muscle. This technique has advantages in patients who have undergone previous blepharoplasty and is particularly appropriate in younger patients with good lid tone and favorable lid position. In cases in which horizontal lower lid laxity is present the transconjunctival procedure can easily be combined with horizontal lid tightening through a tarsal strip procedure. Because the external lamellae are not manipulated, eyelid retraction or ectropion is uncommon after this approach. subcutaneously into the center of the upper lid. The upper lid is retracted upward by a silk traction suture placed through skin, orbicularis muscle, and superficial tarsus. An incision is made in the inferior palpebral conjunctiva, midway between the inferior tarsal border and the inferior fornix, between the temporal and medial ends of the eyelid, using a disposable eye cautery (Fig 1). The lower edge of the divided conjunctiva is retracted downward by the surgeon, while the assistant retracts the adjacent superior edge upward and outward with forceps. Dissection through the underlying Muller's muscle and capsulopalpebral fascia is performed with a disposable

During the past decade, major advances have been made in many crucial areas of the surgical management of hyperparathyroidism. An up-to-date protocol is presented and stresses preoperative localization, operative technique, intraoperative diagnosis, cryopreservation, and autotransplantation designed for practical application.

Although many studies have clearly shown that nasoantral windows do not help ciliary clearance of sinus disease, studies have not addressed the possible adverse effects of nasoantral windows. This study was performed to determine if an inferior antrostomy can actually improve ciliary clearance. Even with the advent of endoscopic sinus surgery we need to have a better understanding of inferior antrostomies.

Advances in the management of premature infants have resulted in improved survival. However, long-term intubation may produce associated laryngeal complications. We report 12 infants and children who developed subglottic cysts following long-term intubation as newborns. The majority of the cysts were in the posterior subglottic larynx. Laser excision of the cysts was undertaken in 8 patients and 3 underwent removal with cupped forceps. Recurrent cysts in 3 patients required more than one endoscopic procedure. The differential diagnosis of stridor in infants who have required long-term intubation includes subglottic cysts. The cysts are not always obvious at endoscopy and indeed may be buried below the mucosa within a soft tissue subglottic stenosis. Their presence may be suspected when tiny beads of mucus are released when laser surgery of a soft tissue stenosis is applied. Successful management of these cysts includes early precise diagnosis, with careful identification of these cysts to differentiate them from other types of subglottic stenosis. An initial attempt of conservative management with endoscopic excision is made. If this fails, an anterior cricoid split may be indicated in cases where the cysts are associated with soft tissue subglottic stenosis. Tracheostomy may be unavoidable in some cases.

A wide variety of benign tumors present in the oral cavity. These tumors are for the most part rare and are classified by the tissue of origin. Although benign oral cavity tumors are not life-threatening, they can result in extensive loss of soft tissue and/or bone. Furthermore, many patients are subject to the threat of recurrence, multiple surgical procedures, and the possibility of malignant degeneration. Because many tumors vary little clinically, an adequate biopsy specimen must be obtained for diagnosis. Radiographs are, in general, nondiagnostic. Collaboration with an experienced pathologist is necessary to determine the tumor's probable clinical behavior. Therapy, which is dictated by tumor type, is almost always surgical.

The vast majority of head and neck nerve tumors are benign. Proper management involves accurate preoperative evaluation and a high degree of suspicion. Ideal treatment involves complete resection but debulking procedures have a definite role. Chemotherapy is reserved for unre-sectable or metastatic disease.